Management of postoperative pain: review of current techniques and methods

A literature review exploring how healthcare professionals contribute to the assessment and control of postoperative pain in older people

Little research has examined the care older people receive in the acute surgical setting. Although pain assessment and management are judged to be a priority in nursing, often pain, in older people, is undermanaged for a variety of reasons. Factors such as stoicism, communication and ageism can shape both the patients' and nurses' attitude towards the perception of pain which subsequently affects pain management. Through a review of the literature, this paper aims to: (i) identify how healthcare professionals contribute to the assessment and control of postoperative pain in older people and (ii) explore potential barriers to achieving more advantageous pain control in this group. It is suggested that to improve pain management there is a need to individualize pain assessment for older people and to assist clinicians with enhancing their education and decision-making abilities in this field. This may best be achieved by supporting a programme of change to develop the skills of staff and encouraging learning through reflective practice. There is however a need for further research in this area.

Postprocedure pain management of interventional radiology patients

Postprocedure pain management of patients after interventional procedures has to take into account residual drug actions from pre- and intraprocedure medications. A variety of sedatives, narcotics, local anesthetics, nonopioid analgesics, and nonsteroidal antiinflammatory agents can be adjusted to the patient's needs and risk factors. The article addresses the safe use of these agents in addition to reflections on assessment and the cognitive elements of the pain experience.

Continuous spinal anaesthesia: what's new and what's not

Continuous spinal anaesthesia combines the advantages of single-dose spinal anaesthesia, rapid onset and a high degree of success, with those of a continuous technique. The introduction of micro-catheters invigorated interest in the technique and allowed its expansion to additional populations and surgical procedures. However, multiple cases of cauda equina syndrome associated with micro-catheters and (primarily) hyperbaric lidocaine solution led to withdrawal of micro-catheters from the US market, casting doubt over the safety of continuous spinal anaesthesia as a whole. A decade after these events it is possible to look back at the experience with continuous spinal anaesthesia for operative anaesthesia and postoperative analgesia and to compare it with the available alternatives. From this perspective, continuous spinal anaesthesia remains a useful and safe technique. Future research should focus on the comparison of continuous spinal anaesthesia with the combined spinal/epidural technique and the use of newer spinal agents.

Local anaesthetic infusion for postoperative pain

The role of continuous bupivacaine infusion either into the wound or as a local nerve block, following hand surgery was investigated in 100 patients. After excluding six patients with complex pain problems in whom neither the bupivacaine infusion nor any other conventional analgesic techniques provided adequate analgesia post-operatively, 86 of 94 (91%) patients were adequately treated for post-operative pain by this system during the first night after surgery when pain is presumed to be greatest. This system also provided adequate on-going analgesia for up to 1 week after surgery, controlling nerve pain and allowing mobilization of tendons after tenolysis. Continuous bupivacaine infusion is of particular use in these two groups of patients and after major hand injuries, when considerable pain can be anticipated. Pain during the first night was not controlled adequately by the bupivacaine infusion system in eight of the 94 patients (8%). All eight had a technical failure of the system, which was rectified in six cases to restore adequate analgesia by the infusion system. Two patients developed infection at the infusion cannula insertion site, which occurred only after 1 week and was successfully treated by removal of the cannula and oral antibiotics.

Postoperative pain control in total joint arthroplasty: a prospective, randomized study of a fixed-dose, around-the-clock, oral regimen

This randomized, prospective study assessed postoperative pain control in 119 patients undergoing total joint arthroplasty. Group 1 (59 patients) received scheduled, around-the-clock, oral opioids and group 2 (60 patients) received oral opioids on an as-needed basis. Both groups had parenteral opioids available for breakthrough pain. The average scores for group 1 were lower than group 2. Differences were significant in sensory scores (AM day 1; AM and PM day 2), affective scores (PM day 2), total pain (PM day 2), visual analog scale (PM day 2), and present pain intensity index (AM day 1; PM day 2). Group 1 averaged 2.05 breakthrough pain doses and group 2 averaged 3.47 doses (P=.003), an average savings of 17.2% of the cost of pain medications during the first 2 postoperative days. The results indicate that scheduled, around-the-clock, oral opioids are an effective treatment regimen for postoperative pain control in total joint arthroplasty patients.

Timing of pre-emptive tenoxicam is important for postoperative analgesia

PURPOSE

In this prospective randomized study, a comparison was made between the efficacy of 20 mg tenoxicam, administered either, 30 min preoperatively or at induction of anesthesia, for the relief of postoperative pain in patients undergoing ambulatory breast biopsy.

METHODS

Seventy-three patients were recruited and all received a standard anesthetic consisting of induction with 2 mg x kg(-1) propofol followed by 5 microg x kg(-1) alfentanyl. No premedication was administered and at the end of the procedure the wounds were infiltrated with 10 ml of bupivacaine (0.5%). Patients were randomized to receive 20 mg tenoxicam intraveneously either 30 min before surgery or at induction of anesthesia.

RESULTS

Demographic criteria were similar in both groups. There were differences in pain scores at 30, 60, 120 and 240 min postoperatively (VAS at 30 min 3.2 +/- 1.2 vs 5.5 +/- 1.8; P < 0.001: VAS at 60 min 1.8 +/- 1.2 vs 3.7 +/- 1.9; P < 0.001: VAS at 120 min 0.9 +/- 0.9 vs 1.7 +/- 1.0; P = 0.003: VAS at 240 min 0.5 +/- 0.5 vs 1.1 +/- 0.8; P < 0.001: Expressed as mean +/- SD). There was a difference in the number of patients requiring additional analgesia, in the first four hours postoperatively (12 (33%) vs 27 (73%); P = 0.001) and a difference in the time to additional analgesia in these patients (87.5 +/- 32.5 vs 55.0 +/- 26.8 min; P = 0.002).

CONCLUSION

Early administration of pre-emptive tenoxicam 30 min before induction of anesthesia improves postoperative analgesia in patients undergoing ambulatory breast biopsy.

Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain

BACKGROUND

Thoracic epidural analgesia is considered the method of choice for postthoracotomy analgesia, but it is not suitable for every patient and is associated with some risks and side effects. We therefore evaluated the effects of an extrapleural intercostal analgesia as an alternative to thoracic epidural analgesia.

METHODS

In a prospective, randomized study, pain control, recovery of ventilatory function, and pulmonary complications were analyzed in patients undergoing elective lobectomy or bilobectomy. Two groups of 15 patients each were compared: one received a continuous extrapleural intercostal nerve blockade (T3 through T6) with bupivacaine through an indwelling catheter, the other was administered a combination of local anesthetics (bupivacaine) and opioid analgesics (fentanyl) through a thoracic epidural catheter.

RESULTS

Both techniques were safe and highly effective in terms of pain relief and recovery of postoperative pulmonary function. However, minor differences were observed that, together with practical benefits, would favor extrapleural intercostal analgesia.

CONCLUSIONS

These results led us to suggest that extrapleural intercostal analgesia might be a valuable alternative to thoracic epidural analgesia for pain control after thoracotomy and should particularly be considered in patients who do not qualify for thoracic epidural analgesia.

Analgesia in day case breast biopsy--the value of pre-emptive tenoxicam

PURPOSE

Inadequate analgesia is a major problem following ambulatory surgery. In this prospective randomised study, the use of pre-operative intravenous tenoxicam (a non steroidal anti-inflammatory agent) was compared with post-incision tenoxicam for the relief of post-operative pain in 77 patients undergoing day case breast biopsy.

METHODS

All patients received a standard general anaesthetic which included infiltration of the wound with bupivacalne after skin closure. Intravenous tenoxicam (20 mg) was administered as a single bolus either 30 min before surgery (37 patients) or after incision (40 patients). Pain scores (100 mm visual analog scale) were obtained at 30, 60, 120 and 240 min after surgery analgesic requirements recorded.

RESULTS

Both groups of patients were similar with respect to age, weight, operative time and length of the incision. Patients receiving the tenoxicam 30 min before surgery had lower pain scores at 30 min (22 +/- 3) vs 46 +/- 3; P < 0.0001), 60 min (9 +/- 2 vs 28 +/- 3); P < 0.0001), 120 min (6 +/- 2 vs 16 +/- 3); P = 0.0002) and 240 min (3 +/- 1) vs 7 +/- 2); P = 0.02) post-operatively. They had a longer time to first analgesia (55.1 +/- 4.6 vs 29.6 +/- 2.6) min; P = 0.0004), required less meperidine (5.4 +/- 2.6 vs 18.8 +/- 3.9) mg; P = 0.007) and were more likely not to require any further analgesia during the first four hours post-operatively.

CONCLUSION

Pre-operatively administered tenoxicam provides superior post-operative analgesia than tenoxicam administered after surgical incision in patients undergoing breast biopsy.

A chart audit reviewing the prescription and administration trends of analgesia and the documentation of pain, after surgery

The report of the joint working party of the Royal College of Surgeons of England, Pain after Surgery, raised many questions in relation to the way pain is managed after surgery. This report questioned many of the existing practices of pain control and highlighted the need for the development of regular pain assessment. The report raised questions regarding PRN (pro-re nata, as needed) prescribing and reinforced the importance of the role of the nurse. This study reviews the way pain is managed in this hospital with regard to analgesia prescribing and analgesia administration trends as well as the documentation of pain. The study was conducted by retrospective review of randomly selected patient charts. The results of this study conclude that documentation of pain following surgery is poor, and needs improvement. Existing prescription trends, in particular PRN prescribing, may be hindering both good practice and the pre-emptive administration of analgesia.

The acute abdomen

Acute abdomen patients present a diagnostic and therapeutic challenge to emergency clinicians. The decision to perform surgery or to treat medically is often difficult to make and requires assimilating patient information, laboratory findings, radiological studies, and DPL. The importance of careful and repetitive PE cannot be overemphasized when managing these patients. If all diagnostics performed are not definitive and the patient continues to exhibit signs of abdominal pain, it is advisable to explore the abdominal cavity while administering supportive measures. Abdominal ultrasonography is emerging as a valuable diagnostic tool for the acute abdomen patient. Laparoscopy, CT, and CAD may also prove useful in certain cases.

A risk-benefit appraisal of injectable NSAIDs in the management of postoperative pain

The inadequacy of pain treatment has been demonstrated in many patient groups suffering from acute pain. The injectable nonsteroidal anti-inflammatory drugs (NSAIDs), including indomethacin, diclofenac, ketoprofen and ketorolac, provide relief from the pain associated with several different conditions. When administered alone or in combination with low doses of opioids, NSAIDs provide good pain relief after musculoskeletal trauma or operation. The main advantage of these agents is that they may form the first-line therapy for pain relief and thus decrease the need of opioids. This avoids respiratory depression which can be associated with opioids. In contrast to opioids, NSAIDs do not cause respiratory depression or have marked adverse effects on the central nervous system. However, they may be associated with adverse effects of the gastrointestinal tract, liver and kidneys, and may increase pre- and postoperative bleeding and cause allergic reactions. These effects are related to the ability of NSAIDs to inhibit prostaglandin synthesis. Use of NSAIDs has to be considered carefully in patients with asthma, allergy to aspirin and NSAIDs, atopy, peptic ulcer or bleeding disorders (such as abnormalities in blood coagulation or coagulation deficits). These considerations are especially important in elderly patients. Having taken these contraindications into account, many clinical studies have demonstrated that NSAIDs are at least as safe as opioids when administered in the short term. However, few studies have specifically monitored adverse effects or included patients over 65 to 70 years of age. In addition, patients with risk factors have often been excluded from the trials. Therefore, the risk-benefit ratio of NSAIDs requires further assessment.

Subcutaneous morphine pump for postoperative hemorrhoidectomy pain management

PURPOSE

Many anorectal procedures are currently being performed on an outpatient basis, hemorrhoidectomy being the exception because of the need for parenteral narcotics postoperatively. We investigated the effectiveness of a subcutaneous morphine pump (SQMP) for outpatient posthemorrhoidectomy pain control.

METHODS

In Phase 1 of our study, 22 patients undergoing radical hemorrhoidectomy were started on an SQMP protocol postoperatively. Twenty-nine patients received conventional postoperative narcotic dosing. In Phase 2, 19 patients enrolled in an SQMP protocol underwent hemorrhoidectomy in an ambulatory setting. Length of hospitalization, catheterization rate, and pain control were evaluated.

RESULTS

In Phase 1, zero patients in the study group and two in the control group required additional hospitalization beyond 23 hours for pain control. The rates of catheterization were similar between the two groups. Pain control was considered satisfactory in 21 of 22 study patients. There was no correlation between pain level and morphine dose. Eighteen of 22 patients experienced minor side effects, necessitating pump removal in two patients. In Phase 2, 18 of 19 patients on the SQMP were discharged from the recovery room. Cost analysis shows the combination of outpatient hemorrhoidectomy and the SQMP to be cost-effective in comparison with an inpatient stay.

CONCLUSIONS

The SQMP enables hemorrhoidectomy to be done on an outpatient basis. It provides effective pain control, enjoys high patient acceptance, and is cost-effective.

Postoperative pain. Analgesics make a difference in many ways

Because pain has so many potent physiologic and psychological effects, successful management of postoperative pain can significantly influence the speed and degree of recovery. Drug therapy combined with nonpharmacologic pain-relief methods and an understanding of each patient's needs are required. Drs Ziser and Murray discuss the types of post-surgical pain experienced by patients and the pharmacologic treatment of this pain.

Patterns of sedation and analgesia in the postoperative ICU patient

Control of pain, discomfort, and agitation is an integral part of the postoperative management of critically ill patients. We examined the sedative and analgesic practices in a surgical ICU during two six-month periods, one in 1986-1987 and the other in 1989-1990. Narcotics, especially morphine and Fentanyl, were the most commonly used drugs. The amount of Fentanyl received by the endotracheal patients in the 1986-1987 group was quite large, 5.5 +/- 4.3 (SD) mg/day. The use of midazolam during the second survey period was associated with a reduced dose of narcotics in artificially ventilated patients receiving continuous intravenous Fentanyl and morphine. The use of epidural Fentanyl, especially following thoracic surgery, was greatly increased during the second study period. More work is needed to assess the effects and effectiveness of ICU sedative and analgesic regimens.